*Warning – the following discusses mental illness and suicide. This may be a trigger for vulnerable community members.
There remain a number of taboos around suicide, rendering seeking help potentially more difficult to seek than it needs to be. Moral, religious and even Aristotle’s economic contribution ideology have historically fed into the taboo that has arisen around both suicide, talking about suicide and living with suicidal ideation.
The rate of suicide in the US is more than twice that of people that die by homicide each year, but we seem to only hear about homicides. In Australia suicide is the leading cause of death for 15 to 44 year-olds. One of the greatest concerns around talking about suicide is that if we bring it up in conversation, we’ll put those thoughts in the person’s head. There is simply not enough evidence to suggest one way or another that direct questioning is helpful or harmful. Here are some thoughts.
Gender and suicide:
In Australia, 80% of completed suicides are men. In 2016 a Black Dog study found the increased risk where the following are present:
– A period of disrupted or depressed mood
– Unhelpful conceptions of masculinity – the ‘tough Aussie bloke’ stereotype in particular
– Social isolation
– At least one personal stressor, like unemployment or relationship breakdown.
Poor mental health remains the most common factor in complete and incomplete suicides, with men in the Black Dog study reporting that unaddressed mental health problems led to an increased inability to manage stressors, leading to unusual decision making and a sense of a lack of resilience (see discussion on resilience here).
In Australia, men complete suicide three times more often than women. Having said that, women are more likely to experience incomplete suicide (formally suicide *attempts*), and over the past year we have seen a 26% increase in completed suicide by women. The highest rate of suicide reported in 2015 was men in 85+ age group with 68 deaths, controversial, though if we could begin to talk about euthanasia (another great taboo), what would this particular rate look like for people over 80 with chronic and terminal illness? I digress.
We also know Aboriginal and Torres Strait Islander people are twice as likely to die by suicide than non-Indigenous people. The only State or Territory to see a decline in suicide rates (2015-16) was South Australia, while all other areas of Australia reported stable or increasing figures.
Since this blog is primarily centred around Bipolar Disorder, let’s talk about that. Bipolar, mental illness and suicide. I’ve got issues, and my diagnosis of Bipolar is the least of them!
I’ve been known to hold controversial opinions via my lived experience of Bipolar Disorder, and while I do not claim to speak for all people with Bipolar, my 20+ years in the area of mental health has confirmed to me some of my views to be held of reasonable truth.
– The distinction between Bipolar I and II and suicidal ideation has most recently been found to be more similar to one another than distinct, as has been historically reported.
– Suicide doesn’t kill us, Bipolar Disorder does.
– A person with Bipolar Disorder can experience suicidal ideation even when well. The thought of cycling through mania and depression when well has been reported to be a factor in ideation while well.
– People living with bipolar have a suicide risk 17 times that of the general population.
– The majority of people with mental illness do not attempt suicide, though, with a condition like bipolar, the connection is undeniably strong: around 1 in 4 people living with bipolar attempt suicide and bipolar accounts for 12% of all suicides each year, while accounting for 2.5% of the population.
– We need to STOP using the term ‘resilience’ and start talking about resourcefulness! (subsequent post to come)
Language and why it matters: Society, community and the personal self.
The Personal Self:
Ever heard someone say “they went psycho”, “he *must* be manic”, “she’s hysterical/manic/insane etc”? These terms have become fair game in the realms of bantering and in *the spirit of fun*, listening to these sorts of throwaway comments is far from fun or jovial, they are thoughtless insults which act to characterise a persons frailty or perceived fault…and it isn’t funny.
Replace any of these terms with words that relate to a persons culture, other disability, HIV status, cancer, chronic illness etc, and well, you get the point. These terms associated with a persons mental health status are often thrown around; at one end subtly implying a person has “psychological disturbances”, through to the other end of the spectrum, as targeted insults towards a person with a mental health problem. Designed to separate the speaker from the *other* person, to state separation, to elevate the speaker, and even where the target isn’t in the room, anyone with a mental health problem (or anyone with half a brain) could see how these words would hurt.
More seriously, these sorts of insults are a form of STIGMA. While stigma is a term which has evaded clear, operational definition, it can be considered to contain three inter-related problems:
– a lack of knowledge (ignorance),
– negative attitudes (prejudice),
– and excluding or avoiding behaviours (discrimination)
For young people, still finding their voice, still working out how to best manage their mental health problem, this type of language acts as a barrier to seeking help. If your child, niece, nephew, etc heard this kind of ignorant speech from you, guaranteed it will lessen the likelihood of them seeking help via you…and that’s a real fucking problem.
As few as 4% of young people with a mental illness seek help from a family doctor or health professional. Primarily they are going to seek help from friends and family, from those they trust, and where we are not aware of the way in which our language hurts and stigmatises mental health problems (and subsequently the young person), the language we use is a contributory factor towards the reluctance of many young people to seek help for mental illness. The good news is that this is reversible. Start to consider the language you use, the way in which you speak to young people around you about mental illness and mental health, since through direct positive contact, it can be extrapolated that for every positive conversation we have with our young people about mental health, it will take 6-8 negative contacts to undo the positive effect our interaction has had.
We’re always telling our young people to watch their language, now we need to watch ours. Doing so is one easy step we can take to encourage young people around us to seek the help they need in relation to their mental health.
The Community Approach:
The jury is out in relation to whether or not we should have direct conversations about suicide with someone who is potentially vulnerable. In Australia we have seen a push towards having these direct conversations, asking the question “are you thinking about suicide?”, though the fact remains, there is simply not enough evidence to say this approach is effective and doesn’t cause further harm.
For people with reduced resourcefulness (a lack of services in their area, a lack of family or friend support, unawareness of what supports are available), potentially asking this direct question can cause further harm since they are left unsupported and with their own thoughts, we simply haven’t done the research to know the results.
Hence at a societal and personal level, reducing stigma is known to increase the likelihood of someone seeking help themselves. There remains a difference between someone coming to you to share their thoughts of suicide, and that of noticing a change in behaviour or having our own worries about someone and asking THE question. With not knowing the impact of asking “are you thinking about suicide?”, surely then addressing any mechanism possible to increase the likelihood of self-help seeking behaviour is key.
Considering the lack of evidence in the area of asking about a person’s suicidal ideation, I would no longer do this, and recommend a more subtle (and potentially more suitable) approach like ensuring the person is aware of professional services in the area; “I’m worried about you. I’m here to listen and I have some help service numbers if you want them?” versus “I’m worried about you. Are you thinking about suicide?”…controversial, I know! and flies in the face of the general approach here in Australia.
Society, community and personal approaches to address suicide:
– Address stigma where and when we see/hear it. Be aware of the language we use, since we know that stigmatising language (even between a parent and child or peer to peer) reduces the likelihood of that person seeking professional help.
– Have a specific mental health curriculum embedded in schools.
– Make crisis support information more readily available. In schools/workplaces/public spaces, have flyers or posters with support service details displayed.
– Target people at higher risk, those with Bipolar Disorder, Schizophrenia, clinical depression.
– Address Indigenous rates of suicide through genuine actions towards enhancing cultural connectedness and individual and kinship autonomy.
– Train up community facilitators to identify those at risk and by building public awareness about mental illness and suicide.
– Provide young people with meaningful engagement and have at hand information in relation to mental health/illness and suicide support.
– Put in place a community-oriented national suicide prevention strategy and action plan which goes beyond clinical support.
– Challenge current approaches to suicide prevention, fund research into approaches and acknowledge findings, even if they are counter to our current approaches.
– Recognise that simply opening up discussion without supports in place may be more of a harm than a benefit.
“Just having a conversation is insufficient. If you go to a high school and you have a suicide expert stand up in front of 1500 students and talk about suicidal warning signs and then leaves and that’s all you do, there is evidence to suggest that that is dangerous.” – Ian Manion, PhD, C. Psych.University of Ottawa.